The University of Massachusetts Medical Center Office-based Continuity
Experience: Are We Preparing Pediatrics Residents for
Primary Care Practice?
Kenneth B. Roberts, MD*; Susan Starr, MEd*; and Thomas G. DeWitt, MD*‡
ABSTRACT. Objective. Surveys of residency gradu-ates and employers have suggested that residency pro-grams do not prepare residents well for practice. Since 1988, pediatric residents at the University of Massachu-setts have been paired one-on-one with an office-based pediatrician for their 3-year continuity experience. This survey was conducted to determine if graduates of such a program are prepared to enter pediatric practice.
Methodology. Graduates of the program from 1991 through 1995 who entered primary care practice were surveyed about their preparedness for practice. The ques-tionnaire was also sent to the residents’ first employers. The 32 questions were directed to overall sense of pre-paredness, ability to manage the pace of practice, com-mon illnesses, comcom-mon behavior problems, anticipatory guidance, office management, and subspecialty prob-lems.
Results. Data from all 25 residents who entered prac-tice and the employers of 20 of the 25 residents were obtained and analyzed. Both groups rated overall resi-dent preparedness to be “prepared” or “very well-prepared” and gave high scores on working at the pace of practice, diagnosing and treating common illnesses, di-agnosing and treating common behavior problems, and providing anticipatory guidance. Areas in which resi-dents were considered to be less well-prepared included anticipatory guidance about nutrition, managing prob-lems by telephone, office management, gynecology, and orthopedics.
Conclusions. The results suggest that continuity ex-periences in office practices are associated with prepara-tion for the pace and types of visits that occur commonly in primary care practice, abilities which previous surveys of residency alumni and employers have found lacking. Some areas may benefit from a formal curriculum which may be implemented in the office practice, at the medical center, or at both sites. Preceptors may benefit from fac-ulty development and continuing medical education that is directed not only at teaching skills but also at content areas which were not addressed in their own residencies. Pediatrics 1997;100(4). URL: http://www.pediatrics.org/ cgi/content/full/100/4/e2; education, medical, graduate;
preparedness for practice; internship and residency; pedi-atrics/education; physicians; evaluation studies; faculty, medical; health maintenance organizations; question-naires.
ABBREVIATIONS. AAP, American Academy of Pediatrics; UMMC, University of Massachusetts Medical Center; HMO, health maintenance organization; DBP, developmental and behav-ioral pediatrics.
T
hroughout the past 20 years, multiple surveys have documented that graduates of pediatrics residency programs have not felt prepared to practice primary care pediatrics.1– 4 Concurrentas-sessments of the curriculum of residency programs, beginning with the report of the American Academy of Pediatrics (AAP) Task Force on Pediatric Educa-tion in 1978, demonstrated that primary care aspects of pediatric practice were given little time and em-phasis.2,5,6Recently, directors of managed care
orga-nizations have added their dissatisfaction with the preparedness of graduates of pediatrics residency programs to practice in their settings.7,8
Multiple changes to the traditional residency cur-riculum have been proposed to address the
Resi-dency-Practice Training Mismatch.7–12At the University
of Massachusetts Medical Center (UMMC), the re-sponse included moving the resident continuity ex-perience from hospital clinics to practices. This re-port describes a survey of UMMC residency graduates and their first employers, to determine resident preparedness for primary care practice.
DESCRIPTION OF RESIDENCY PROGRAM
UMMC is the only tertiary care center in central Massachusetts for children beyond the neonatal pe-riod. Rotations are offered in every pediatric subspe-cialty. In 1987, the Division of General and Commu-nity Pediatrics changed its model for the continuity experience, recruiting community practitioners as preceptors and initiating a faculty development pro-gram.13 Since July 1988, residents have been paired
one-on-one with office-based pediatricians for their entire 3-year continuity experience. Matching is based on interview visits and mutual selection. The hospital-based clinic was closed, and a faculty group practice was begun, with a pediatrician recruited from office practice as the director. This practice was not used as a training site for incoming residents between 1988 and 1990. Once the transformation
*From the Department of Pediatrics, University of Massachusetts Medical Center, Worcester, Massachusetts.
Dr Roberts is currently at Moses Cone Health System, Greensboro, North Carolina.
Dr DeWitt is currently at Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.
Received for publication Feb 27, 1997; accepted May 13, 1997. Reprints not available.
Address correspondence to Kenneth B. Roberts, MD, Pediatric Teaching Program, Moses Cone Health System, 1200 North Elm Street, Greensboro, NC 27401.
from clinic to practice was accomplished, faculty whose primary function was primary care practice were recruited as preceptors and paired one-on-one with residents in the same fashion as practitioners in the community. Thus, some residents have been in the community and some at the hospital, but all have been in office practices. The community sites have included offices of a staff model health maintenance organization (HMO), traditional “private practices,” and two sites affiliated with the medical center (a community health center and an office practice).
The goals of the office-based portion of the resi-dency are to prepare graduates to practice primary care pediatrics and to provide an office-based per-spective to graduates who enter a subspecialty. The residents go to their office site 1 to 2 half-day sessions a week and have a 4-week block rotation in each year of training. Residents build their own panel of pa-tients. A data system which tracks each patient visit is used to assure that residents see children of vari-ous ages, from newborns to adolescents. First year residents initially are allotted 60 minutes for health supervision visits and 30 minutes for sick visits; be-fore the end of the 3 years, these visits are being scheduled for no longer than 30 minutes and 15 minutes, respectively, closer to the pace expected in practice; the ability to increase the pace is facilitated by a low broken appointment rate in the practices and the opportunity to add acute illness visits. The preceptors are graduates of the year-long basic fac-ulty development program on teaching skills and meet regularly throughout the year to review pro-gram and resident goals. Additional “nuts and bolts” of the program are described elsewhere.14
THE SURVEY INSTRUMENT
A questionnaire was mailed to the 37 residents who graduated from the residency between 1991 and 1995 and who completed a minimum of 2 years in the program. Questionnaires were also sent to the first employers of the 25 residents who entered pri-mary care practice.
The survey form instructed graduates to reflect back to their first few months in primary care prac-tice and employers to reflect on the new employee’s first few months of job performance. The survey included a question about overall sense of prepared-ness; employers were also asked to compare the res-ident to graduates of other residency programs they may have hired (if any). An additional 31 questions were directed to specific areas: preparedness to per-form at the pace expected in practice, preparedness to diagnose and treat common illnesses and behavior problems, preparedness to provide anticipatory guidance, preparedness to practice without re-sources of a medical center, preparedness to work with special populations, preparedness in office management issues, and preparedness to treat sub-specialty problems.
A 5-point Likert scale was used. A score of 1 indicated not at all prepared, a score of 2 indicated minimally prepared, a score of 3 indicated fairly well-prepared, a score of 4 indicated well-prepared,
and a score of 5 indicated very well-prepared. Addi-tional narrative comments were solicited.
RESULTS (TABLE 1)
Surveys from all 25 residents who entered primary care practice were completed and used in the analy-sis. Of the 25 residents, 12 (48%) had their continuity site in various offices of an HMO, 6 (24%) had been in “private practices,” and 7 (28%) had been either in the UMMC practice or at a UMMC-sponsored com-munity site. The distribution of employment sites differed from this pattern: 7 (28%) practiced in HMO sites, 13 (52%) in “private practices,” and 5 (20%) in other settings, such as the Indian Health Service and
TABLE 1. Means of the Responses of Residents and Their First Employers to 32 Questions Regarding the Residents’ Preparedness for Primary Care Practice in the First 1 to 2 Months After Gradu-ation From Residency*
Residents (N525)
Employers (N520)
1. Overall sense of preparedness 4.3 4.7 1b. Compared to new graduates of other 4.7
programs (if any) (N515)
2. Working at the pace expected in practice
4.2 4.5
3. Charting/documentation 4.6 4.5
4. Independently diagnosing and managing common illnesses
4.3 4.8
5. Independently diagnosing and managing usual behavioral problems
4.2 4.4
6. Providing anticipatory guidance about:
a. Developmental issues 4.4 4.5
b. Behavioral issues 4.3 4.4
c. Health promotion/disease prevention
4.2 4.6
d. Safety/injury prevention 4.1 4.5
e. Nutrition 3.3 4.4
7. Relating to office staff 4.5 4.7
8. Practicing without resources of medical center immediately available
3.6 4.3
9. Using community resources for individual patient care
3.2 4.3
10. Working successfully with special populations:
a. Difficult patients 3.8 4.5
b. Patients with chronic conditions 3.5 4.7 c. Patients from other cultures or
who speak other languages
3.4 4.3
d. Underserved patients 3.8 4.4
11. Knowledge about and ability to participate in management decisions about:
a. Patient scheduling 3.0 4.0
b. Medical record keeping 3.6 4.3
c. Medical/legal issues 3.1 4.1
d. Cost effective medical practice 3.1 4.3 12. Managing problems by telephone 2.9 4.5 13. Office management of subspecialty
problems:
a. Cardiology 3.6 4.6
b. Dermatology 3.7 4.3
c. Endocrinology 3.3 4.6
d. Gastroenterology 3.4 4.4
e. Gynecology 2.7 3.9
f. Hematology 3.4 4.5
g. Infectious diseases 4.1 4.6
h. Neurology 3.8 4.5
i. Orthopedics 3.0 4.4
j. Pulmonology 4.3 4.5
an academic medical center. Of the 25, 4 stayed in the same office in which they had their continuity expe-rience. The employers of 20 of the 25 graduates re-sponded; of the 5 who did not respond, 4 were no longer in the practice and could not be located (in-cluding 3 from the Indian Health Service), and 1 did not respond despite multiple requests.
The responses of both graduates and employers to “overall preparedness for practice” were either “well-prepared” or “very well-prepared.” The em-ployers of 15 graduates also had experience with graduates of other programs and rated all 15 Univer-sity of Massachusetts graduates as “very well-pre-pared” compared with the graduates of other pro-grams. Of the other 31 questionnaire items, which attempted to measure particular components of the primary care curriculum, the means of the resident self-ratings exceeded “well-prepared” for 11 compo-nents and were less than “fairly well-prepared” for only 2 items, gynecology and managing problems by telephone. Only one of the employer rating means was below “well-prepared” (gynecology, mean of 3.9).
Both groups rated preparedness in independently diagnosing and managing common illnesses and be-havior problems to be in the “well-prepared” to “very well-prepared” range. Written comments by residents identified the opportunity to see both acute illness visits and health supervision visits in the of-fice to be valuable; in particular, learning the ofof-fice treatment of common acute illnesses provided a use-ful contrast to the emergency department treatment of the same complaints. In the five anticipatory guid-ance areas, resident means were between “well-pre-pared” and “very well-pre“well-pre-pared” for all except nu-trition; employers rated residents “well-prepared” to “very well-prepared” for all five. Practice manage-ment issues received means between “fairly well-prepared” and “well-well-prepared” from residents and employer means were between “well-prepared” and “very well-prepared.” Managing problems by tele-phone was one of only two mean scores in the resi-dent’s self ratings below “fairly well-prepared” (2.9); employers rated them between “well-prepared” and “very well-prepared.”
Among the subspecialty problems represented in primary care practice, residents felt “well-prepared” in infectious diseases and pulmonology; the two mean scores at “fairly well-prepared” or below were in gynecology (2.7) and orthopedics (3.0). Employers also rated resident preparedness lower in gynecol-ogy (3.9) than in the other nine subspecialty areas, which received mean scores between “well-pre-pared” and “very well-prepared.”
DISCUSSION
The traditional approach to assessing the primary care component of residency programs has been to focus on readily available quantitative measures, such as the number of patients seen or the amount of time spent, rather than on outcomes. Residents as-signed to private practices have been reported to see more patients per session than those assigned to hospital clinics or publicly-funded community
clin-ics,15,16 but the significance of the additional
experi-ence per se is not clear. Osborn et al15compared the
performance of residents in different types of conti-nuity sites on the American Board of Pediatrics In-Training Examination and the Behavioral Pediatrics Examination. Residents in private offices had equiv-alent scores on the In-Training Examination and higher scores on the Behavioral Pediatrics Examina-tion than residents at the university clinic or in public clinics, but the process of assignment was by choice rather than random and the amount of time in the various settings differed, precluding a definitive con-clusion about the independent effect of the setting or of the number of patients seen.
The current study attempted to assess prepared-ness to practice primary care pediatrics upon grad-uation from a residency in which all residents par-ticipated in an office-based continuity experience, whether at the hospital or in the community. Resi-dent self-evaluation was used as one measure, rec-ognizing the limitation that residents tend to rate themselves lower than other evaluators rate them on the same task.17,18Proposed explanations of this
phe-nomenon are that trainees have difficulty defining behavioral criteria against which to measure them-selves; that they tie self-assessments to stable, glob-alized attributions of ability; and that they fault themselves for not having lived up to unrealistic expectations.19
Employer evaluation was used as another impor-tant outcomes-oriented measure. Previous surveys have not found such employer satisfaction with new graduates.7,8In this survey, employers rated the
res-idency graduates “well-prepared” or “very well-pre-pared” in absolute terms and relative to graduates of other programs.
Overall Preparedness
The UMMC resident response on question 1, “overall sense of preparedness” was a mean of 4.3, or between “well-prepared” and “very well-pre-pared.” This would seem to echo other studies in which graduates express satisfaction with their residency program,1,4,11but the current survey
dif-fers from previous ones in an important way. In previous surveys, all of the graduates were asked to rate their satisfaction with various aspects of their residency experience. In the UMMC survey, the subset of residents who chose to practice pri-mary care pediatrics were asked to rate their prep-aration for practice. Comparable elements of the questionnaires from previous surveys suggest that preparation for primary care practice was not rated as highly as overall satisfaction with the program. For example, in the most recent survey published, the score given to the quality of prep-aration in primary pediatric care clinic (noted by the authors to be equivalent to continuity clinic) was 2.86 on a 5-point scale similar to the one used in the University of Massachusetts survey.1
their pediatricians. A 1993 survey of managed care organizations, conducted by the Group Health Asso-ciation of America under contract to the federal Health Resources Services Administration, asked the medical directors of managed care practices the question: “How well do residency programs prepare primary care physicians for practice in managed care settings?” The responses of the medical directors were: 62%, “poorly prepared”; 32%, “prepared”; and 6%, “well-prepared” (Fig 1).7 In 1994, a separate
study contracted by Health Resources Services Ad-ministration reported that 13 of 23 HMOs did not believe their primary care physicians were well trained for HMO settings and respondents from 4 additional HMOs had serious concerns in specific areas such as resource management, working in a team, managing a patient’s care, prevention, and patient education.8
In contrast to these previous surveys, the UMMC study indicates high employer satisfaction, both in absolute terms and compared with graduates of other programs, with no rating below “well-pre-pared.” The employer responses for the seven resi-dents who went to work in managed care settings were similar to the overall group, with two responses of “prepared” and five responses of “very well-prepared.”
Developmental and Behavioral Pediatrics (DBP)/Anticipatory Guidance
The 1978 AAP Task Force Report identified goals for residency curriculum, including increased em-phasis on biosocial and developmental problems of children and adolescents. To train pediatricians who are skilled in these areas, the report suggested that residents spend more time in ambulatory experi-ences, provide continuous care for a group of their own patients, and develop skill in anticipatory guid-ance, developmental appraisal, screening, and refer-ral.5Studies assessing progress in the years after the
Task Force Report identified that change came very slowly.2,6Although a 1989 survey similar to the one
used by the 1978 Task Force found that graduates after 1984 thought their training was better in DBP and adolescent medicine, 50% of the 1785 member sample still considered their training insufficient in biosocial areas.2
In comparison to these studies, UMMC residents rated themselves “well-prepared” to provide antici-patory guidance and manage common behavioral issues; employers also rated residents between “well-prepared” and “very well-prepared.” In the UMMC residency curriculum, DBP received a two-pronged approach, taught by preceptors in the of-fices and by faculty at the medical center, with each resident having two 4-week DBP rotations. There was considerable interaction between DBP faculty and the preceptors at faculty development sessions. Groups were begun for preceptors (and other pedi-atricians in the area) to present cases for discussion with DBP and child psychiatry faculty; a similar group was conducted for senior residents, in which monthly sessions were conducted jointly by a senior DBP faculty member and a practitioner-preceptor. It is likely that the combined approach contributed to the graduates’ sense of preparation in this area.
Office Management
Residency programs have been criticized for not preparing graduates in practice management issues, particularly those related to managed care. The Council on Graduate Medical Education reports that, despite concern by many physicians about managed care, more than 75% of physicians have at least one managed care contract, and almost 50% are involved with at least one HMO.20Of the preceptors of UMMC
residents, 45% are employed by a staff-model HMO, and the other 55% have more than one managed care contract. Studies of practicing physicians affirm the need for more training in cost-effective care. Gradu-ates from the University of California, San Diego, between 1979 to 1988 reported that their lowest per-ceived comfort level was in “economics of pediatric practice.”3Cantor et al11found that 81% of physicians
were satisfied overall with their training, but only 46% rated training in “cost-effective medical care” as excellent or good, and only 4% thought they were prepared for “management aspects of your practice.” Studies of internal medicine residents and family physicians report similar results.21,22
The results of the UMMC study show that resi-dents rate themselves lower in management issues than in other areas. Immersion in the clinical activi-ties of a practice may prepare the resident to work at
the pace expected in practice and to function without the resources of a medical center immediately avail-able, but it does not guarantee recognition of the structure of the practice or management issues such as the use of the telephone. These issues require formal attention, such as a curriculum on telephone triage skills.
Subspecialty Areas
For primary care pediatricians to be the initial managers of subspecialty problems, they need a firm basis in subspecialty areas.23Regarding “office
man-agement of subspecialty areas,” residents felt least prepared in gynecology (2.7) and orthopedics (3.0). Women graduates gave slightly higher scores in gy-necology than men, but both genders reported feel-ing less than “fairly well-prepared” (women 2.8, men 2.5). Gynecology and orthopedics have been identi-fied as weaknesses in previous surveys. In the 1978 AAP Task Force Report, 66.9% of practicing physi-cians surveyed reported a low feeling of competence when dealing with gynecology, and 73.9% said they had insufficient training in that area.5 In the same
survey, 55.9% of physicians reported a low feeling of competence when dealing with orthopedics, with 60% reporting insufficient training; a recent study also identified orthopedics as an area of weakness.3
Employers perceived residents to be “well-pre-pared” to “very well-pre“well-pre-pared” in 9 of the 10 sub-specialty items, the exception being in gynecology. The largest difference between employer responses and resident self-ratings was in orthopedics.
The similarity between the subspecialty areas in which the residents felt relatively unprepared and those identified by the AAP Task Force on Pediatric Education and subsequent studies as inadequately stressed in residency programs is provocative. It is quite possible that the preceptors may have limita-tions teaching in these areas because of their own lack of preparation in residency or because they have little opportunity to maintain skills in their practices or both. In support of this hypothesis are the results of a separate survey of preceptors, which asked what content areas the preceptors would most like to ad-dress in monthly Continuing Medical Education ses-sions designed specifically for them (“Community Teaching Rounds”). The preceptors chose topics re-lated to gynecology, orthopedics, nutrition, psycho-pharmacology, and behavior. The implication for faculty development programs for community pre-ceptors is that, in addition to building teaching skills, consideration should be given to the clinical content and skills practitioners might need.24
A combined approach (medical center and office practices), such as described above in DBP, may be useful, as suggested by the responses regarding pre-paredness in gynecology; coincident with the recruit-ment of additional adolescent medicine faculty and the initiation of required rotations in adolescent medicine, the scores in “gynecology” increased from an mean of 2.5 for the residents who graduated in 1991 to a mean of 3.3 for those who graduated in 1995. In both DBP and adolescent medicine, the strat-egy chosen has been to develop an integrated
curric-ulum with primary care rather than to depend on totally independent rotations.
Limitations of This Study
Because there was not a uniform period of time in the present study from completion of residency to the time of the survey, it is possible that graduates with a longer period may not have rated their prep-aration the same as those with a shorter period. The direction of possible bias is hard to predict: perhaps those in practice for a few years have a better idea of what they did not know at first and, therefore, rate their preparation lower; or those in practice for only a few months might still feel anxious and, therefore, rate their preparation lower. In fact, the variation from year to year was slight, with the means of overall preparation for the five cohorts being 4.3, 4.3, 4.3, 4.2, and 4.2.
The high rating of resident preparedness for prac-tice is associated with the change in residency cur-riculum of conducting the continuity experiences in office practices. However, no data are available be-fore the change in curriculum to permit a compari-son; moreover, other changes were made in the cur-riculum as well, in areas such as DBP and adolescent medicine, which likely contributed to the outcome.
The number of resident graduates is small, because of the small size of the program (7 residents per year) and the restriction to graduates who entered primary care practice. Confirmation is required from larger programs or from multiple programs using commu-nity-based primary care education.
It could be argued that residents who were ori-ented toward primary care preferentially selected the University of Massachusetts residency because of the opportunity to establish a continuity practice in the community. This selection bias is unlikely to account for the high preparedness scores in the early years of the program, before the reputation of the program was established, and the overall preparedness means do not vary by year of graduation as demonstrated above. Moreover, the rate of graduates entering pri-mary care practice was 67.5% during the years of the study, comparable to the percentage of first-time candidates for certification by the American Board of Pediatrics in 1995 (67.2%).25
Implications
1. The most important finding of the survey is that both the residency program graduates feel pre-pared and their employers rate the graduates as well-prepared to very well-prepared for practice. After 3 years in the office setting for their conti-nuity experience, the residents feel prepared for the pace of practice and the evaluation and man-agement of the types of visits that occur com-monly in office practice.
2. One notable difference between the results of this survey and the 1978 AAP Task Force Report and related studies was in preparedness to evaluate and manage developmental and behavioral issues and to provide anticipatory guidance. The rela-tively high ratings may relate to the combined teaching approach taken in the residency pro-gram, utilizing both medical center faculty and community practitioners, a strategy that may be useful in other areas as well.
3. The survey demonstrates that practice manage-ment education does not happen by osmosis; physical presence in the practices is insufficient to assure recognition of the structure of the practice or management issues such as the use of the tele-phone. A more formal process, including curricu-lum, is required.
4. Preceptors, who may themselves be graduates of programs that gave little attention to areas such as orthopedics and gynecology, may have difficulty teaching in those areas without assistance. Faculty development and continuing medical education programs directed in these areas may result in increased teaching abilities and expanded clinical abilities.
Conclusions
Three years of primary care continuity experience in an office practice is associated with a high level of resident preparedness for practice, as determined by the graduates and their employers. Foci of relative weakness remain, however; practice management and certain subspecialty areas, which need to be addressed explicitly, either by combining office-based training with medical center programs or by developing curricula for practitioner-preceptors. Pre-ceptors may themselves benefit from continuing medical education in the same areas.
REFERENCES
1. Liebelt E, Daniels S, Farrell M, Myers M. Evaluation of pediatric training by the alumni of a residency program. Pediatrics. 1993;91:360 –364 2. Wender EH, Bijur PE, Boyce WT. Pediatric residency training: ten years
after the task force report. Pediatrics. 1992;90:876 – 880
3. Taras H, Nader P. Ten years of graduates evaluate a pediatric residency program. Am J Dis Child. 1993;144:1102–1105
4. DeAngelis C, Duggan A, Oski F. Twenty-five years of residents: what and where they are now. Pediatrics. 1990;85:10 –16
5. American Academy of Pediatrics. Report of the Task Force on Pediatric
Education. Chicago, IL: American Academy of Pediatrics; 1978
6. Weinberger HL, Oski FA. A survey of pediatric residency programs 5 years after the task force report. Pediatrics. 1984;74:523–526
7. Palsbo S, Sullivan C. The Recruitment Experience of Health Maintenance
Organizations for Primary Care Physicians: Final Summary Report.
Wash-ington, DC: Group Health Associates of America, Inc; 1993
8. Felt S, Frazer H, Gold M. HMO Primary Care Staffing Patterns: A
Cross-Site Analysis of 23 HMOs. Rockville, MD: Health Resources Services
Administration; 1994
9. Reuben DB, McCue JD, Gerbert B. The residency-practice training mis-match. Arch Intern Med. 1988;148:914 –919
10. Jacobs MO, Mott P. Physician characteristics and training emphasis considered desirable by leaders of HMOs. J Med Educ. 1987;62:725–731 11. Cantor JC, Baker LC, Hughes RG. Preparedness for practice: young physicians’ views of their professional education. JAMA. 1993;270: 1035–1040
12. Greenberg LW, Getson P, Brasseux C, et al. How are pediatric training programs preparing residents for practice? Am J Dis Child. 1991;145: 1389 –1392
13. DeWitt TG, Goldberg RL, Roberts KB. Developing community faculty: principles, practice and evaluation. Am J Dis Child. 1993;147:49 –53 14. Sargent JR, Osborn LM, Roberts KB, DeWitt TG. Establishment of
primary care continuity experiences in community pediatricians’ offices: nuts and bolts. Pediatrics. 1993;91:1185–1189
15. Osborn LM, Sargent JR, Williams SD. Effects of time-in-clinic, clinic setting, and faculty supervision on the continuity clinic experience.
Pediatrics. 1994;91:1089 –1093
16. Rice TD, Holmes SE, Drutz JE. Comparison of continuity clinic experi-ence by practice setting and postgraduate level. Arch Pediatr Adolesc
Med. 1996;150:1299 –1304
17. Stuart MR, Goldstein HS, Snope FC. Self-evaluation by residents in family medicine. J Fam Pract. 1980;10:639 – 642
18. Nathan R. Using an in-training examination to assess and promote the self-evaluation skills of residents. Acad Med. 1992;67:613
19. Gordon MJ. A review of the validity and accuracy of self-assessments in health professions training. Acad Med. 1991;66:762–769
20. Council on Graduate Medical Education. Sixth Report. Managed Health
Care. Implications for the Physician Workforce and Medical Education.
Rock-ville, MD: Council on Graduate Medical Education; 1995
21. Wartman SA. Managed care and its effect on residency training in internal medicine. Arch Intern Med. 1994;154:2539 –2544
22. Mann K, Chaytor K. Help! Is anyone listening? An assessment of learning needs of practicing physicians. Acad Med. 1992;67:S4 –S6 23. Charney E. The education of pediatricians for primary care: the score
after two score years. Pediatrics. 1995;95:270 –271
24. Roberts K, DeWitt T. Faculty development of pediatric practitioners: complexities in teaching clinical precepting. Pediatrics. 1996;97:389 –393 25. Stockman, J. Annual Report of the President of the American Board of
Pediatrics to the Association of Pediatric Program Directors. Chapel Hill,
DOI: 10.1542/peds.100.4.e2
1997;100;e2
Pediatrics
Kenneth B. Roberts, Susan Starr and Thomas G. DeWitt
Experience: Are We Preparing Pediatrics Residents for Primary Care Practice?
The University of Massachusetts Medical Center Office-based Continuity
Services
Updated Information &
http://pediatrics.aappublications.org/content/100/4/e2
including high resolution figures, can be found at:
References
http://pediatrics.aappublications.org/content/100/4/e2#BIBL
This article cites 20 articles, 6 of which you can access for free at:
Subspecialty Collections
_management_sub
http://www.aappublications.org/cgi/collection/administration:practice Administration/Practice Management
b
http://www.aappublications.org/cgi/collection/medical_education_su Medical Education
following collection(s):
This article, along with others on similar topics, appears in the
Permissions & Licensing
http://www.aappublications.org/site/misc/Permissions.xhtml
in its entirety can be found online at:
Information about reproducing this article in parts (figures, tables) or
Reprints
http://www.aappublications.org/site/misc/reprints.xhtml
DOI: 10.1542/peds.100.4.e2
1997;100;e2
Pediatrics
Kenneth B. Roberts, Susan Starr and Thomas G. DeWitt
Experience: Are We Preparing Pediatrics Residents for Primary Care Practice?
The University of Massachusetts Medical Center Office-based Continuity
http://pediatrics.aappublications.org/content/100/4/e2
located on the World Wide Web at:
The online version of this article, along with updated information and services, is
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.
